1.0 Fte Care Coordinator

Position Summary:
Reporting to the Manager of Patient Care, Care Coordinators are responsible for assessing, planning, coordinating, implementing and reviewing patient's care needs and services provided by HCCSS following Ministry of Health legislation and HCCSS HNHB policies and procedures. Care Coordinators are also responsible for providing information and/or referring patients to alternative community resources.

There are two functional areas within Care Coordination: Community and Access. Within the Community Care Coordination are specialty teams to address some of the unique service needs in our service area. Access refers to the Intake Care Coordination functions performed through our hospitals, community intake and after hours Care Coordinators.

Core Duties - Responsibilities:
**Identification and Engagement**:
- To respond to inquiries and requests for service in accordance with the patient's care needs, identified risk factors, and urgency for services;
- To provide the patient with information about legislation, Home and Community Care Support Services, client rights and responsibilities, and services available.
- To problem-solve inquires and issues with the patient's needs and service provider’s need.
- To obtain consent for the gathering and sharing of patient information.

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**Patient Assessment**:

- To determine eligibility and assess for Home and Community Care Support Services;
- To determine capability and assess for placement into long term care facilities;
- To counsel patient and family regarding the placement process; to understand the crisis component of urgent placement needs;
- To plan for discharge;
- To respect the patient's privacy, autonomy, ethnic, spiritual, linguistic, familial and cultural differences.

**Client Safety**
- Promotes client safety in alignment with the Vision, Mission, Values and Strategic Directions of Home and Community Care Support Services.
- Works within the basic principles of client safety by doing the right thing for the right client, using the right method at the right time.
- Adheres to Home and Community Care Support Services' client safety policies and procedures.

**Accessing Resources and Linking**:

- To assist patients to access alternative community resources by providing appropriate information and referral.

**Service Planning**:
- To develop a service plan that reflects the patient's assessed needs.

**Goal Setting**:

- To establish goals in collaboration with the patient to ensure goals reflect the patient's desired outcomes, within the resource parameters of Home and Community Care Support Services.

**Service Implementation and Coordination**:

- To implement a coordinated service plan that reflects the patient's needs and goals for service.

**Monitoring and Reassessment**:

- To monitor progress towards established goal;
- To reassess referral to appropriate team;
- To reassess for ongoing eligibility and continuing needs for service; to discharge services when appropriate;
- To link patient to other community services.

**Resource Management**:

- To authorize the appropriate Home and Community Care Support Services HNHB services to ensure the effective and efficient utilization of resources.

**Fiscal Accountability**:

- To order, allocate, and authorize services and manage expenditures within the Service Planning and Ordering Guidelines (units of service);
- To negotiate visits frequency with patient and service providers and problem solve discrepancies regarding billing with service providers.

**Evaluation**:

- To evaluate patient satisfaction with services, and to identify opportunities to improve the delivery of Home and Community Care Support Services HNHB Services;
- To identify trends that will impact Home and Community Care Support Services resources;
- To complete service feedback forms.

**Documentation**:

- To maintain professional and Home and Community Care Support Services documentation in accordance with professional documentation standards including the completion of appropriate forms;
- To maintain accurate electronic client files.

**Community Relations**:

- To interpret the Home and Community Care Support Services HNHB services to patients, families, community groups, and other health/social services providers through presentations and panel participation;
- To develop partnerships with others in the community.

**Other Related Tasks**:

- Collaborates with team members regarding work flow coverage
- Precepts and mentors staff. Acts as a resource to other staff to assist in orientation, implementing change, and problem solving.
- Assists with projects and new initiatives as they relate to position.
- Participates on committees.
- Promotes Best Practices and helps define best practices.
- Promotes and supports research initiatives.
- Participates in relevant educational opportunities.
- Other duties as assigned.

Qualifications:
**EDUCATION**:

- A University Degree. An equivalent of education and expe